Application for Gem Replenishment Authorisation

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..... MSME IEM Registration Number, Udyog Aadhar Number Issuing Authority Date of Issue Products for which registered Status House Details Star Rating Certificate No. Issuing Authority Date of Issue Valid upto Export Details Sr. No. Shipping Bill No. Shipping Bill Date Port of Export Country of Export Invoice Number of the Shipping Bill Serial Number in the voice Number ITC(HS) Code Total Quantity Unit of measure code FOB value in Rs. FOB value in USD FOB value realized in the foreign currency code Foreign Currency code Repository Data Description of Item of Exports Total FOB (In INR) Total FOB (In USD) Replenishment/Entitlement Details i) Details as per Appendix -4F Sr.No Shipping Bill No. Shipping Bil .....

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..... thorisation Claimed (USD) Late Cut Sub Total as per Export Product as per Appendix 4G Sr.No Import Item Replenishment Rate (% Of FOB) FOB value Realised (INR) FOB value Realised (USD) Replenishment Authorisation Claimed (INR) After Late cut Replenishment Authorisation Claimed (USD) After Late cut Value of Authorisation Claimed as per Appendix 4F (in USD) Value of Authorisation Claimed as per Appendix 4F (in INR) Totals Total Value of Authorisation Claimed(ln INR) Total Value of Authorisation Claimed(ln USD) Attachment Details Attachment Type Remark Attachment Name DECLARATION / UNDERTAKING 1. I/We hereby declare that the particulars and the statements made in this application are true and correct to the best of my / .....

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..... / We hereby declare that no export proceeds are outstanding beyond the prescribed period as laid down by RBI or such extended period for which RBI permission has been obtained. 7 I hereby certify that I am authorised to verify and sign this declaration as per Paragraph 11.06 of the FTP. üTick the box as acceptance of declaration/ undertaking and fill in the details below. Place Date Name Designation Email Mobile Office Address Residential Address DSC / E-Sign Details S.No E-sign Type Serial Number Signed Date Certificate Type Certifying Authority Common Name Organisation Certificate Issued Date Certificate Expiry Date GUIDELINES FOR APPLICANTS [Please see paragraph 4.35 of FTP and 4.58 of HBP] 1. Applicat .....

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